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Diagnostisch rapport. CVA, Ergo leerjaar 1 kwartaal 2
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Diagnostisch rapport, casus CVA. Gemaakt in leerjaar 1, kwartaal 2 ergotherapie
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By: linaaabbadi • 5 year ago
By: RUSHILG • 5 year ago
just good
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By: marenegeluk • 5 year ago
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4-12-2017 Diagnostischrapport
Diana Cornet, CVA
Sarah
STUDENTNUMMER
KLAS
DOCENT
,Inhoudsopgave
Algemene gegevens......................................................................................................................................2
Begeleidende brief.......................................................................................................................................3
Vormgeving diagnostische fase....................................................................................................................4
Ordening in inhoudsmodel...........................................................................................................................5
Ergotherapeutisch probleemdefnitie...........................................................................................................7
Globaal behandelvoorstel ............................................................................................................................8
Bijlagen.......................................................................................................................................................10
Afgenomen assessments........................................................................................................................10
COPM.................................................................................................................................................10
Observatie..........................................................................................................................................14
Doelmatigheid........................................................................................................................................15
Verantwoording......................................................................................................................................16
Refectie..................................................................................................................................................17
1
, Algemene gegevens
Cliëntgegevens
Naam: Diana Cornet
Geboortedatum: 15-03-1968
Geslacht: Vrouw
Adres: Rochussestraat 56
Telefoonnummer: 010-1234567
BSN: 4567890
Verzekeraar – polisnummer: Menzis, 1234456
Huisarts: Dr. Klaasen
Gegevens ergotherapeut:
Naam: Sarah Willemse
Werkzaam bij: Revalidatie Rijndam
E-mailadres: Sarah-willemse1@hotmail.com
Telefoonnummer: 0610413344
Werktijden: Ma t/m Do, 8:00-16:30 u.
Verwijzer
Naam: Dr. Zwam
Functie: Revalidatiearts
Werkzaam bij: Revalidatie Roterdam
E-mailadres: zwam@revalidatieroterdam.nl
Telefoonnummer: 010-1236789
Werktijden: Ma-vrij 08.30-17.00 u.
Datum verwijzing: 3-12-2017
Medische diagnose
CVA rechts, links aangedaan.
Hulpvraag
Diana is sinds deze week overgeplaatst van het ziekenhuis naar Revalidatie Roterdam. Doelstelling is
terugkeer naar huis. Graag diagnostiek en oefening van vaardigheden die hiervoor nodig zijn.
2
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